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Post-TKA mechanical thromboembolic prophylaxis found safe and effective
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A multimodal regimen using no chemical agents for preventing thromboembolism following total knee arthroplasty has been found to be safe and effective, according to a retrospective database review at a single center.
“While the current standard of care mandates that a chemical agent be used for deep venous thromboses (DVT) prophylaxis, this study shows that a multimodal program — without a chemical agent — can lead to a low rate of DVT and pulmonary embolism,” said principal investigator William G. Hamilton, MD, of Anderson Orthopaedic Clinic in Alexandria, Va., where the preferred strategy is been multimodal.
Outcomes of the study were presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. The retrospective review consisted of 4,061 total knee arthroplasties (TKAs) performed between 1994 and 2007: 2,263 patients had single TKA; 899 patients had bilateral TKA.
Mechanical compression
Patients were risk stratified, so those with a history of thromboembolism or pulmonary embolism were prescribed adjusted-dose warfarin (coumadin). In addition, mechanical compression — primarily through A-V Impulse foot pumps and thigh-high stockings — was applied preoperatively to the nonoperative leg and immediately postoperative to the operative leg in all patients.
Patients were mobilized early and taught ankle pump exercises. Physical therapy often began the day of surgery. Routine Doppler ultrasound, at 4 to 6 weeks postoperative, was also standard.
“We have given no routine chemoprophylactic agents for many years now,” Hamilton said.
Litigation free
In the study, 84% of patients had ultrasound. “Anyone who did not have ultrasound was asymptomatic,” Hamilton told Orthopedics Today. Of the 2,660 patients who underwent ultrasound, 77 DVTs were identified in 73 patients, for an overall DVT rate of 2.74%.
Database review revealed two patients had symptomatic pulmonary emboli, and five had bleeding complications in the knee. “However, we had no mortalities in that first 4- to 6-week period,” Hamilton said. Furthermore, over the past 20 years, “we have had no litigation related to our thromboembolic prophylaxis.”
Hamilton noted that this prophylaxis remains controversial. “We have conflicting recommendations from chest (physicians) and more recently from our own academy, which leaves us unsure which protocol is best for our patients,” he said.
This study has several weaknesses, he noted. It is a retrospective review; there is no comparative group; there may have been complications that were not captured, patients may have used a chemical agent without investigator knowledge. Still, this study shows that using risk stratification and a multimodal program of prophylaxis can lead to a low rate of DVT, low costs, and the lowest risk of wound and bleeding complications possible. Hamilton believes that in the coming years there will be a trend away from classic chemical anticoagulants agents to treat TKA patients.
He said in the coming years there will be a trend away from the classic chemical anticoagulant agents to treat TKA patients. “The ease of administration and cost savings makes our protocol attractive,” he said. – by Bob Kronemyer
Reference:
- Hamilton, WG; Reeves, JD; Fricka, KB; et al. Isolated mechanical thromboembolic prophylaxis following total knee arthroplasty. Paper 151. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.
William G. Hamilton, MD, can be reached at Anderson Orthopaedic Clinic, 2501 Parkers Lane, Alexandria, VA 22306; 703-892-6500; e-mail: billhamilton@cox.net.
